Basic Information
Provider Information | |||||||||
NPI: | 1972025021 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RYE | ||||||||
FirstName: | HEIDI | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, AGACNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WELLNITZ | ||||||||
OtherFirstName: | HEIDI | ||||||||
OtherMiddleName: | M. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3200 E RACINE ST | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535462343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083718000 | ||||||||
FaxNumber: | 6083718939 | ||||||||
Practice Location | |||||||||
Address1: | 3200 E RACINE ST | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535462343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083718000 | ||||||||
FaxNumber: | 6083718939 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2017 | ||||||||
LastUpdateDate: | 10/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 7750-33 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1972025021 | 05 | WI |   | MEDICAID |